Today was a pretty solid day. The friar, my chronic care doc, really pushes me hard to think. I’m having to remember those silly details from step 1 studying and apply them to the real world. He tells me I’m the most experienced student medically he’s ever had and yet I have a few glaring weaknesses. I’m terrible with presenting cases and gloss over some details that I should be digging into a lot more. I’m just happy to have something to work on and improve and happy that he’s straight up with me about what I need to change. An interesting case today was where this 40 year old white male came in for a thumb that started swelling three weeks after a dog bite. He had tried to pry open his dog’s mouth as it was attempting to eat his girlfriend’s cat. Unfortunately, the cat didn’t make it. Fortunately, they are still dating. We also had this 90 year old man as a new patient who had a tractor fall on him more than ten years ago and crush his spine and pelvis. He’s barely able to walk and has no bladder control yet seems to be totally content with life and was making bets as to how long he is going to live. At first he said he would keep breathing til 95 and then asked why not just go to 100. Talking with a man like that who continues to dream is just inspiring. He just is one of those that will never quit, never stop fighting. In addition to this fun stuff, I presented a case on catscratch disease which is always pretty fun. So basically today I learned to stay away from cats. Lastly, I found this awesome coffee shop in the center of the city that always has excellent live music, so I’m going to stop typing and enjoy it for a bit. Adios!
Saw some sad things today. The worst was a poor 30 year old girl with pretty much every autoimmune disease known to man. She appears to be 80, has lost several fingers, has been in ICU multiple times, always has to be on an IV, and basically has the worst genetics I’ve ever seen. If you are ever thinking you are having a bad day, you’re not (outside of tragedies of course). The things I complain about just don’t even come close to comparing to what this girl has to face day in and day out. She came in today because of stomach pain. She has gastroparesis (and many many other issues) and every time she eats she gets terrible shooting pain along the area of her descending colon. In addition to that, her abdomen grows incredibly distended for a few days at a time, so much so that people think she’s well into a pregnancy. It was so sad but what was amazing to me about her was that on her list of 20+ meds she didn’t have a single one for pain. We get those fat middle aged guys with “back pain” that just want a few hits of dilaudid, Percocet and oxy, and here is a person who actually has real pain and she just toughs it out. We had someone who was on morphine and oxycontin telling us about the pain they had and I couldn’t even imagine how he could feel anything! Speaking of addicts, I’ve gotten pretty comfortable talking to people about drug and alcohol abuse (definitely not uncommon in this clinic) and today I have a new record for what is to someone, “Just a few beers”… 18… If that’s just a few, how many is a lot??? Anyways, for another update on general life, the Jordanian restaurant is delicious and doesn’t tear apart GI.
Today was really nice actually. For the first time, we were not only on time but early. Working well as a team and getting faster and faster and at the same time a higher quality of service. We even took on another doc’s procedure at the end of our day just to have some fun. You always here funny things from patients and today I decided to copy one of these delightful quotes… This is coming from a 48 year old white male who has a BMI greater than 60, is shorter than me (I’m certainly not the tallest person in the world) and is over three times my weight (I’m around 160 so you can do the math)… Before I start with the quote… wow! Just imagine. At my dad’s office we would get similar people coming in and asking why their knees hurt… haha clearly the result of an autoimmune disease with the famous mnemonic FiM, which, of course, stands for Fork in Mouth. But this one guy had spent some time in a nursing home and on describing it, he said, “They were poisoning me for a month. They were only giving me canned food. I had to stop eating.” Haha I believe you my man! But not eating isn’t a bad thing right now! Man, I love moments like that. Just gotta laugh and roll with it. Besides that, it was really neat that a lot of grandparents brought in their kids today so I got to tell jokes and talk about Spongebob and Star Wars, two things I’m much more comfortable with than abnormal vaginal bleeding. And speaking of that, one of my patients and I were both speaking to each other in our second/third language and I’m having a little trouble understanding… Next thing you know, he’s pulling his clothes off and showing off a nice rash and I’m like, “Wait man! We haven’t even introduced ourselves.” Haha the life! As a side note, I also ate with Dr. Leonidas at a Jordanian Restaurant today and lived through it. So far, no ill effects, but we’ll see. Brace yourselves.
Life got crazy for a bit there and I had no time to write! Alas, I’ve missed a few days, but the show must go on! Let’s begin with our day of chronic care. I’ll call my doctor for this rotation the Friar (not sure why I went with that… he’s definitely not a fan of religion… but the name seems to fit). So the Friar has a bit different approach to medicine than Dr. Leonidas and certainly a different environment medically. Where I have been seeing uninsured people for the most part in my family rotation, in chronic care I see extremely wealthy people that never really worry about the costs of medicine. It’s a private setting and patient satisfaction surveys and the need to keep patients drive the doctors to overprescribe medications such as antibiotics and narcotics (I actually haven’t seen the Friar prescribe narcotics without good reason but just trying to make a general statement). He told me that the antibiotics that he prescribes are not needed 1/3 of the time but if he didn’t prescribe them the patients would simply go to an urgent care, get the meds, and would be lost to his practice. This really disappoints me. I know it is an extremely common theme in medicine to overprescribe so I’m not down on this doc at all but more on the whole medical system and the flippant mindset so many have towards antibiotics in particular. Doctors who prescribe like this are unfortunately increasing the rates of antibiotic resistant bugs and this trend towards hitting viruses with a Z pack is going to lead to billions of deaths in the long run. We study this stuff for 8 years and then go through more training with residency and fellowships oftentimes, yet we let our patients who have used google all of 2 hours tell us how much of and what medicine they need… yeah right. If a surgery isn’t necessary, don’t make the first cut. If it is possible to use steri strips rather than sutures, use the tape. A cardiologist was recently destroyed legally (I actually think he may be in jail) and barred from practicing medicine after it was found that he was doing unnecessary caths for financial gain. How is a doctor that is prescribing an unnecessary medicine in order to keep patients (and thus financial gain) not also barred? Again, not down on this particular doctor but the whole system that teaches doctors to do this. This is when those lectures we slept through on patient education are vital. I think about half of docs may really agree with what I wrote and half would be pretty pissed off (and listing three reasons why I’m wrong), but it’s how I feel and research shows that unnecessary meds increase mortality – Primum non nocere – First, do no harm.
To go on with patients and what this blog is meant to talk about, I saw a guy (in chronic care with the Friar) who had been in the hospital for an incredibly severe bout of pancreatitis and is now insulin dependent. He was a pretty solid guy who no one would ever have guessed was an alcoholic. Great family and job, exercises daily, doesn’t smoke, and just a flat out cool guy. He’s one of those you would want in your clinic but everyone has something, some struggle, some temptation that comes at them again and again and is too often hidden in the shadows. Unfortunately, this temptation almost cost him his life. He is now completely off of alcohol and is getting back into regular life again thankfully with a lot more help and honesty about where he is at. It’s incredible when someone gets hit with something like a month in the ICU and then changes their life. All the time that the nurses and docs worked on him was worth it. I’m hoping to follow him as a patient and see what happens and how he grows. In the family med clinic, I sewed up a guy that chopped his foot with a machete. Practical takeaway point – don’t hit foot with machete. We told him it would cost extra to sew his shoe as well haha. It was nicely sutured and I felt proud of this one. I’ve been doing paps and pelvic exams lately like a master and feel like I’m really helping the whole office. We’re halfway through and hopefully I will improve as much as I have in the next three weeks as the first.
Rough day but the good news is our Argentinian patients didn’t kill me for having a German background. Wasn’t so sure what would happen after the Deutschland won the World Cup. Today, had a patient yelling at me and telling me how much of a Christian he is but all doctors are liars and that they are all going to hell. He expressed his well thought out ideas, accusations, and theology with frequent demonstrations of eloquent diction (many words of which happened to start with the letter F). There were a few times that I wanted to have some fun and point out the contradictions but felt that frustrating him more might get me shot which would have made it a very bad day. I haven’t tried pulling out bullets and stitching myself in a mirror but I can imagine that would be difficult. But we went on with this lovely conversation and when I told him we’d include Dr. Leonidas in our discussion he decided that he didn’t want to wait and stormed out the main doors. We can’t make anyone stay in the office, and this was actually a fairly life threatening disease that he had. So well, good luck to you my fleeing patient. The doc and I would have liked to help you but you can only help people that want to be helped. This guy had a rapidly falling INR (low INR = high clots) despite high Coumadin and could clot up at any time. He also left the ER despite medical advice on the contrary a few days before. Today though, we actually did help people get better (always a plus in the medical field). We used some needles and scalpels and drained this giant cyst a 30 year old had on his lower quad for his whole life. Not sure why he decided now was the time to take care of it, but I’d bet a woman was involved. It didn’t smell thankfully but it looked like a bottle of brown toothpaste was being squeezed out (imagine this next time you’re brushing your teeth haha). The other funny thing I heard today was from this girl who tattooed very expensive skulls and flowers all over her body and then started to complain to us about the reasons she couldn’t afford healthcare. Smoking and tattoos? I just can’t understand why you don’t have money… Haha this is real life.
Doctor Leonidas is the man. He had to go to one of those fantastic computer training courses in the middle of the afternoon and just told me not to worry about coming back in because there would only be a couple of patients late. This meant I went out on the town and lived it up… Or found an incredible coffee shop for studying… Or both! What a day. My medical Spanish is coming along, now I only really have any difficulty talking with Cubans but I feel like I’m even starting to understand that. My little reggaeton radio station is doing its job. The most interesting, yet sad, case of the day was a 48 year old white woman who looked to be 80 years old. She had at least 60 pack years (2+ packs a day for 30 years) and noted a slowly enlarging mass in the right side of her throat 5 months ago. As it’s grown larger, she has had increased difficulty swallowing solids [very important to differentiate solid and/or liquid dysphagia. Thanks Dr. Goljan (actual name for once!)!], terrible hoarseness, and choking throughout the night. A lot of our patients wait until the disease is terrible before coming in and unfortunately I just don’t know what we’re going to be able to do for her. Discussing this case with my attending was just so sad. If she would have come in 4 months ago, maybe we could have saved her and hopefully we still will, but the prognosis is most certainly very, very poor. On a brighter note, drug and company reps brought in slurpees today in honor of 7/11!
It’s a bit weird to give sex advice to a little 75 year old Hispanic lady but hey, I can cross that off my bucket list. But I was like the Love Guru today, discussing all sorts of things such as a woman complaining that her man was too well endowed, chatting about varicoceles and “shaving” with a college student who had Asperger’s and helping a man decide which bed to buy for his wife. Haha I conveniently failed to mention that I’m not even dating at the moment, I figured that would invalidate all I had to say. I saw a man with a lower leg amputation, and I like that now I’m allowed to be curious. At one point in my life, I wouldn’t bluntly ask someone how they lost a limb or ear or eye for fear of being rude. Now, that sort of question is expected both by my attending and my patient. Anyways, I ask, and he just popped off his prosthetic (it makes a weird suction sound… won’t forget that) and showed me how it all worked and I was just fascinated. Ends up he had Reiter’s Syndrome which we remember in med school by the famous mnemonic “Can’t See, Can’t Pee, and Can’t Climb a Tree”. It’s a genetic (75% associated with HLA B27) syndrome characterized by conjunctivitis, urethritis, and reactive arthritis (hence the mnemonic) and is usually preceded by a chlamydia infection but is also associated with many others. The results are typically not terrible but were devastating for this poor man. Outside of the lost leg, he had multiple plates in one shoulder, bilaterally in the wrists, and in his remaining ankle. Thankfully he only had slightly decreased and blurry vision. Well, saw some other cool things but that was the most interesting today. Peace out.
Chronic care – saw some patients. Two hours of lecture on prescription writing – aka write legibly and pay attention. The real elephant in the room though was of course we received our Step 1 scores today. All of us looked up our scores differently. I wouldn’t open the email until I was back at my house all alone where others opened theirs while driving to work in the morning! I definitely would have crashed. I came out of the 8 hour nonsense test last month feeling horrible, worried about passing, and upset that I had wasted two years of my life. Anyways today, I’m sitting at my couch, finally alone and able to just think of this one thing. I had to calm down, slow my breathing, pray, and remind myself again and again that I’d given my all and that I could do nothing more. I opened it, heart pounding, sweating, feeling some chest pain (probably in need of a little nitroglycerin), and almost cried from relief. I passed and even beat my original goal. The beautiful thing about my score is that I’m not limited. Most residency programs have a cutoff and I’m above what I need for anything I’ve considered. So excited and happy, but most of all relieved. No more golgi apparatus or endoplasmic reticulum or IL-8 or any of the things that only matter to researchers for the rest of my life! Haha well unless I go into research but at the moment, that is HIGHLY doubtful! Some of the best students (intelligence, compassion, and just pure doctoring skills) I know did not do as well as expected. Clearly the test doesn’t demonstrate some of the most important qualities. I’m just disappointed that we’re judged on test scores that really don’t matter in the grand scheme of things. Regardless, I can finally look back at this monster of a test for which we spent two years preparing, raise my hands, and say, “I did it.”
“But I will trust in you, O Lord. I say, ‘You are my God.’ My times are in your hands.”
Today was really exciting and full of new procedures. I did a pap smear, placed sutures and removed an epidermoid cyst for the first time. Well, I guess I should say I did my first sutures on a living person… I guess I’ve already practiced suturing on cadavers and pig’s feet. Regardless, everything turned out good. Just as I was leaving to go to dinner with some good friends, I got a call that someone had just sliced up their finger so I went back in got a kit prepared and practiced sewing. Who would’ve thought med school would make me into a seamstress? The good news is we saved the finger, the bad news is I showed up very late for dinner. But when you show up in scrubs and have a cool picture, all is forgiven. Man, what a fun day though, the patients were excellent, outside of one who amused us greatly by leaving just when we arrived to his room! Haha what can you do? We’re in an “almost” free clinic, people aren’t going to be seen as soon as they walk in the door and if they’d like to leave then so be it. We treat everyone we can as best as possible. I met a lovely older patient from Chile, where I learned to speak Spanish, and it was just incredible to finally hear someone with what is in my mind the correct accent. It was clear and crisp and I was just happy that I understood everything. She was trying to set me up with her daughter but I kinda feel there is probably a law against that… Granted, I definitely need to look that up and see, just in case!
Family Med – Rural Clinic
Today I met my favorite patients yet. They were two young Venezuelans who came to America fleeing the brutal treatment of the government against the opposition party (more specifically, the murders of their family and friends). As a side note, it’s amazing how much is going on in the world that I’ve never heard about. It just makes me wonder why sirens, megaphones, CNN, and social media aren’t blaring out the harsh realities that so many face day in and day out in our world. I hope the reason for this lack of information is totally political because my alternate theory, that we just don’t care about the suffering of others, would reveal something terrifying about how our country has decayed. Regardless, medically, the young man presented to the clinic for a bad case of onychomycosis (aka nail fungus) of the great toe that had unfortunately become infected. At first we didn’t think it was infected but then it started oozing yellow liquid and we quickly had a change in opinion… this guy was in need of some solid antibiotics right away. I loved that he was so excited when I told him he was still allowed to work as long as he covered the nail. Already in this clinic, I’ve seen that the majority of immigrants work wherever and however they can; it’s refreshing to see people give their all. The girl that was with him laughed at my Spanish and sat me down and taught me to say words correctly. The Audacity! Haha but really, I was so appreciative because they just smiled at my mistakes, slowed things down and simplified their words as best they could, and helped me to get better. Outside of that, I gave a few knee injections, saw Grave’s disease for the first time, and learned more about calming angry patients. All in all, an excellent day finished with a long run and a glass of wonderful wine.